Health, Nutrition and Population

Poverty is both a consequence and a cause of ill health. Ill health, malnutrition, and high fertility are often reasons why households end up in poverty, or sink further into it if they are already poor. The illness of a household breadwinner and the consequent loss of income can undermine a poor household’s ability to cope financially. Out-of-pocket payments for health services—especially hospital care—can make the difference between a household being poor or not. High fertility additionally places an extra financial burden on households, by diluting the resources available to other household members and by constraining earning opportunities, especially for women.

Poverty is also a cause of ill health. Poor countries and poor people suffer from a multiplicity of deprivations which translate into levels of ill health that far exceed the population average. Most obviously, they lack the financial resources to pay for health services, food, clean water, good sanitation, and the other key inputs to producing good health. It is not just lack of income that causes the high levels of ill health among poor people, however: the health facilities serving them are often dilapidated, inaccessible, inadequately stocked with basic medicines, and run by poorly trained staff. Furthermore, the poor are also disadvantaged by a lack of knowledge about prevention and when to seek health care. They also tend to live in communities that have weak institutions and have social norms that are not conducive to good health. In short, poor people are caught in a vicious cycle: their poverty breeds ill health; and this in turn conspires to keep them poor.

Governments can improve the health of poor people. Health, along with education, is seen as one of the key ultimate goals of development, and increasingly is seen as a dimension of poverty in its own right. This is reflected in the fact that no fewer than four of the seven international development goals (IDGs) relate to health, broadly defined. Governments can do much to improve the health of their populations, and especially of the poor. They can mitigate the effects of low income on health outcomes by reducing the price poor people pay for health and other key goods and services, through, for example, health insurance, fee-waivers, and targeted food subsidies. Governments can also reduce the non-income disadvantages faced by poor people: they can (1) improve poor people’s access to and knowledge of health services; (2) improve the quality of services that poor people use, both in technical terms and by making them more user-friendly; and (3) get services more focused on the interventions that are relevant to the health profile of poor people. Improving the health of poor people means contemplating action on several fronts. The main objective of this chapter is to provide guidance on accomplishing this. One point needs emphasizing at the outset: funds linked to poverty reduction strategy papers (PRSPs), including debt relief or IDA credits, will have a far greater impact on poor countries’ health levels if they are accompanied by a thorough review of existing policies and by a willingness to link new spending with reforms that make health systems work better, especially for the people they tend to serve least well—the poor.

Governments can reduce the impoverishing effects of ill health. By improving the health of their populations, governments can reduce income poverty. They can also reduce income poverty indirectly, by reducing the impact of ill health on household living standards; for example, by modifying health financing arrangements to ensure that people do not face large out-of-pocket payments when they fall ill. This is sometimes called the financial protection goal of health systems; it is clearly a secondary goal to that of improving health, but is nonetheless an important one. Other parts of government also have a role to play here; for example, by introducing schemes to provide income support to households where the breadwinner is ill and unable to work. The second objective of this chapter is to provide guidance on what health ministries can do to reduce the impoverishing effects of ill health. (See chapter 17, Social Protection, for discussion of what other parts of government can do on this issue.)

The role of government. In countries as poor as those preparing PRSPs, funds are extremely limited and it is vital that they be used wisely to ensure they have the greatest impact. Governments cannot do everything, and in the health sphere they never will. Good health in any case is not just about what goes on inside health clinics and hospitals—good health can be produced in many ways, and central to this process are people, as members of households and as members of communities. This is not to belittle the role of governments. Governments have a key role to play, and fulfilling that role is not just a question of pumping money into health services. Services need to be relevant, accessible, and affordable to poor people. There has to be coordination between government and the other actors in the health system, such as donors, NGOs, and community organizations. Actors in the system have to be kept well informed about the costs and benefits of different health interventions, about best practices in their delivery, about the health risks associated with certain activities and products, about the opportunities for obtaining care from different providers, and so on. Good government also entails reaching out across ministries. In short, a good government is as much a steward of the health sector as it is a financier and provider of health services.

The different levels of government action. Putting together policies aimed at improving the health of poor people and reducing the impoverishing effects of ill health requires thinking broadly, but it also means thinking across all the relevant levels of policymaking. The first of these is the macroeconomic level—the level of the government’s national budget. Here the major concern is the amount of resources allocated to health, but an important secondary concern is the possible reallocations of budgets to reach poor people better. The second level is the health system, where the concern is to put together reforms and improve incentives to get the system to function better for poor people. The third level is the microeconomic or service delivery level, where the focus should be on how to implement specific activities to reach poor people. Work at these three levels is interdependent: those working at the project or service delivery level cannot succeed without the cooperation and assistance of those at the systems and spending levels. The PRSP represents an opportunity for all people working at all three levels to work together.

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